Bilevel Positive Airway Pressure Therapy Research Articles

Clinical Feasibility of an Auto-Adjusting Bi-Level PAP Device for the Treatment of Obstructive Sleep Apnea

Summary Introduction: Bi-Level positive airway pressure (BPAP) is an effective alternative to continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) who could not tolerate CPAP. An automatically titrating BPAP device has recently been developed, BPAP Auto® with BiFlex™ (BPAPauto). The primary aim of this study was to examine the performance of this new device during attended polysomnography (PSG). Materials and Methods: This was a prospective case series study. Participants with OSA currently using CPAP or BPAP therapy were recruited and undergo in-lab PSG study with BPAPauto. Results: A total of 27 participants met the criteria, enrolled the study. All participants received BPAPauto therapy during an attended PSG. Sleep and respiratory data were examined. The mean apnea hypopnea index was found 2.2±2.5 events/hour. SaO2 (oxygen saturation) was 94.0%±1.8. The mean inspiratory positive airway pressure (IPAP) abolish respiratory events was 14.1±3.4 cmH2O and that of expiratory positive airway pressure (EPAP) was 10.7±3.9 cmH2O. Conclusions: BPAPauto is able to establish an appropriate Bi-Level PAP and control oxygen saturation without excessive disruption of sleep. Further studies using randomized control design are needed to examine potential roles and advantages of BPAPauto for treatment of OSA. (JTSM 2014;3:66-70)

Adaptive servo-ventilation as treatment of persistent central sleep apnea in post-acute ischemic stroke patients

BackgroundAdaptive servo-ventilation (ASV) is a well-established treatment of central sleep apnea (CSA) related to congestive heart failure (CHF). Few studies have evaluated the effectiveness and adherence in patients with CSA of other etiologies, and even less is known about treatment of CSA in patients of post ischemic stroke. MethodsA single-centre retrospective analysis of ASV treatment for CSA in post-acute ischemic stroke patients without concomitant CHF was performed. Demographics, clinical data, sleep studies, ventilator settings, and adherence data were evaluated. ResultsOut of 154 patients on ASV, 15 patients had CSA related to ischemic stroke and were started on ASV a median of 11 months after the acute cerebrovascular event. Thirteen out of the 15 patients were initially treated with continuous positive airway pressure (11/15) and bilevel positive airway pressure (2/15) therapy with unsatisfactory control of CSA. ASV significantly improved AHI (46.7 ± 24.3 vs 8.5 ± 12/h, P = 0.001) and reduced ESS (8.7 ± 5.7 vs 5.6 ± 2.5, P = 0.08) with a mean nightly use of ASV of 5.4 ± 2.4 h at 3 months after the initiation of treatment. Results were maintained at 6 months. ConclusionASV was well tolerated and clinically effective in this group of patients with persistent CSA after ischemic stroke.

Early dentofacial orthopedic treatment of a patient with maxillary hypoplasia and congenital central hypoventilation syndrome

Congenital central hypoventilation syndrome (CCHS) is a respiratory disorder characterized by compromised central and peripheral chemoreflexes that lead to hypoventilation during sleep. All patients with CCHS require lifelong ventilatory support during sleep; however, nasal bilevel positive airway pressure (BiPAP) therapy can cause maxillary hypoplasia. In the present case, the patient had been diagnosed with CCHS and was initiated on BiPAP therapy at the age of two months. The patient presented to our orthodontic department with severe midface hypoplasia along with an anterior dental crossbite at the age of five years. An orthodontic appliance (facemask) was prescribed to assist forward growth of the nasomaxillary complex. The patient was instructed to wear the facemask together with the BiPAP appliance while sleeping and for as long as possible when awake. Orthopedic treatment for at least one year resulted in favorable forward growth of the maxilla and reduced facial concavity.

Resistin and Cardiac Remodeling in Patients with Obstructive Sleep Apnea

Background: Resistin is an adipocytokine, associated with obesity and inflammation. Its exact role in insulin resistance and diabetes is still controversial, but there is now enough data, concerning its direct effects on myocardial cells. The relation between resistin plasma levels with risk of new onset heart failure in humans has been confirmed in several large studies. Materials and methods: Resistin plasma levels were measured in 30 patients with obstructive sleep apnea and mild systolic dysfunction (ejection fraction 45, 7% ± 6, 17%), and compared to fifteen patients with obstructive sleep apnea and normal ejection fraction (ejection fraction 60, 3 ± 6, 3%). The effect of bilevel positive airway pressure therapy was evaluated during a three month follow-up in 19 patients. The dynamics of markers of haemodynamic stress – NT-pro-BNP was determined in addition. The association between resistin, obesity, insulin resistance and severity of obstructive sleep apnea was analysed. Results: Resistin plasma levels were significantly higher in the group with mild systolic dysfunction in comparison to those with preserved ejection fraction (6, 92 ng/ml vs 2, 78 ng/ml). This difference lost significance after adjustment for confounders. In a linear regression analysis resistin levels were not associated with body mass index, obesity, homeostasis model assessment- index, systolic and diastolic blood pressure, or obstructive sleep apnea severity. Though not of statistical significance its plasma levels, decreased (8, 53 vs. 4, 16 ng/ml; p-0, 12) as a result of a three-month bilevel positive airway pressure therapy. Conclusions: According to our data it is elusive to determine whether resistin plasma levels are associated with early myocardial damage. Its application for the monitoring of the effect of bilevel positive airway pressure therapy is tentative.

Progress Toward a Clearer Understanding of the Role of Bilevel Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Progress Toward a Clearer Understanding of the Role of Bilevel Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Analysis of bilevel positive airway pressure therapy in children based on weight

Obesity as a comorbidity adds a challenge when treating children presenting to the PED in status asthmaticus. Bilevel positive airway pressure (BiPAP) is an accepted treatment modality for children in status asthmaticus. Our purpose was to analyze BiPAP use and outcomes for children with status asthmaticus and obesity in our PED.

Application of Dual Mask for Postoperative Respiratory Support in Obstructive Sleep Apnea Patient

In some conditions continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP) therapy alone fails to provide satisfactory oxygenation. In these situations oxygen (O2) is often being added to CPAP/BIPAP mask or hose. Central sleep apnea and obstructive sleep apnea (OSA) are often present along with other chronic conditions, such as chronic obstructive pulmonary disease (COPD), congestive heart failure, pulmonary fibrosis, neuromuscular disorders, chronic narcotic use, or central hypoventilation syndrome. Any of these conditions may lead to the need for supplemental O2 administration during the titration process. Maximization of comfort, by delivering O2 directly via a nasal cannula through the mask, will provide better oxygenation and ultimately treat the patient with lower CPAP/BIPAP pressure.

Systemic BCG-Osis as a Rare Side Effect of Intravesical BCG Treatment for Superficial Bladder Cancer

Intravesical Bacilli Calmette-Guérin (BCG) immunotherapy is a commonly used treatment for superficial bladder cancer. Although the treatment is well tolerated in 95% of cases, life-threatening side effects including BCG sepsis can occur. This report describes the case of an 82-year-old man with a background of lung disease. He developed septic shock and type two respiratory failure after receiving the sixth installation of intravesical BCG (TICE strain) immunotherapy for recurrent bladder Transitional Cell Carcinoma in situ. Despite the early initiation of broad spectrum antibiotics (tazocin and gentamicin), he remained pyrexial. There was a rapid deterioration, and on the second day of his admission, he developed type two respiratory failure secondary to Acute Respiratory Distress Syndrome (ARDS) prompting transfer to Intensive Care for Bilevel Positive Airway Pressure (BiPAP) Ventilation. The blood cultures taken before the induction of antibiotics results were negative. Increasing clinical suspicion of systemic BCG-osis prompted the initiation of antituberculosis therapy (ethambutol, isoniazid rifampicin) and steroids. Following six days of BiPAP and anti-tuberculosis therapy in ITU, his condition started to improve. Following a prolonged hospital stay he was discharged on long term ethambutol therapy. BCG-osis is a well-known though rare side effect of intravesical BCG therapy. We would like to highlight the importance of having a low threshold for starting anti-TB treatment.

Treatment of Central Sleep Apnea in US Veterans

There are no standard therapies for the management of central sleep apnea (CSA). Either positive pressure therapy (PAP) or supplemental oxygen (O(2)) may stabilize respiration in CSA by reducing ventilatory chemoresponsiveness. Additionally, increasing opioid use and the presence of comorbid conditions in US veterans necessitates investigations into alternative titration protocols to treat CSA. The goal was to report on the effectiveness of titration with PAP, used alone or in conjunction with O(2), for the management of CSA associated with varying comorbidities and opioid use. This was a retrospective chart review over 3 years, performed at a VA sleep disorders center. The effects of CPAP, CPAP+O(2), and BPAP+O(2), used in a step-wise titration protocol, on consecutive patients diagnosed with CSA were studied. CSA was diagnosed in 162 patients. The protocol was effective in eliminating CSA (CAI ≤ 5/h) in 84% of patients. CPAP was effective in 48%, while CPAP+O(2) combination was effective in an additional 25%, and BPAP+O(2) in 11%. The remaining 16% were non-responders. Forty-seven patients (29%) were on prescribed opioid therapy for chronic pain, in whom CPAP, CPAP+O(2), or BPAP+O(2) eliminated CSA in 54%, 28%, and 10% cases, respectively. CPAP, CPAP+O(2), and BPAP+O(2) each produced significant declines in the AHI, CAI, and arousal index, and an increase in the SpO(2). The data demonstrate that using a titration protocol with CPAP and then PAP with O(2) effectively eliminates CSA in individuals with underlying comorbid conditions and prescription opioid use. Comparative studies with other therapeutic modalities are required.

Pre-hospital improvised bronchodilator therapy of a patient on bi-level positive airway pressure therapy

Patients suffering acute breathlessness is a common emergency situation, many patients with airways disease require bronchodilator therapy with (3-agonists. To assist the management of these cases paramedics use guidelines drawn up by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). They provide guidance on the management of most situations paramedics are likely to encounter. However, there will be occasions when paramedics are called to deal with a situation which is outside of their experience and the JRCALC guidelines do not provide the appropriate guidance required to fully inform clinical decision making. In the UK telephone support from a physician skilled in the specific discipline they require is generally not available, so paramedics have become skilled at improvising. This case study describes such an improvisation, in the management of acute breathlessness in a patient who is on home bi-level positive airway pressure (BiPAP) therapy.

Noninvasive mechanical ventilation with BiPAP therapy for comatose exacerbation of chronic obstructive pulmonary disease through an endotracheal tube: is it justified?

Noninvasive mechanical ventilation with BiPAP therapy for comatose exacerbation of chronic obstructive pulmonary disease through an endotracheal tube: is it justified? Antonio Esquinas,1 Ritesh Agarwal21Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain; 2Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiaWe read with interest the paper by Rawat et al1 related to the role of bilevel positive airway pressure (BiPAP) delivered via endotracheal tube in unconscious patients suffering from acute exacerbations of chronic obstructive pulmonary disease in a real-world situation. Although the authors provide some justification for the use of BiPAP through an endotracheal tube, we believe that this technique is fraught with complications and should not be routinely employed. In fact, three patients failed BiPAP therapy, two patients received conventional invasive ventilation, and one patient failed to respond to BiPAP. Thus, almost 30% of patients either failed or showed no evidence for benefit of BiPAP. Further, the authors provide no data on the amount of leakage that was present while administering BiPAP therapy. The authors also do not provide details on whether the nurses/chest therapist administered intermittent manual bag ventilation. Ideally, the authors should have referred the patients on manual bag ventilation to another public health center where facilities for invasive ventilation are available free of cost.View original paper by Rawat and colleagues.

Role of BiPAP applied through endotracheal tube in unconscious patients suffering from acute exacerbation of COPD: a pilot study.

Background and objectivesMechanical ventilation is the recommended treatment in unconscious patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) and hypercapenic respiratory failure. But, in resource-poor countries, many of these patients are not able to afford this treatment due to financial constraints. The main aim of this study was to evaluate the usefulness, safety and cost-effectiveness of bilevel positive airway pressure (BiPAP) applied via endotracheal tube in such patients.MethodsTwenty patients with acute exacerbation of COPD and altered sensorium, who were unable to afford ventilatory support, were intubated and BiPAP therapy was provided to these patients through the endotracheal tube. The outcome of these patients was studied.ResultsThe BiPAP success rate and hospital mortality were 85% (17/20) and 15% (3/20) respectively. BiPAP failure was associated with high sequential organ failure assessment (SOFA) score at the time of admission (P = 0.002). Improvement in Glasgow coma scale (GCS) score (P < 0.001), pH (P = 0.001), PaCO2 (partial pressure of carbon dioxide) (P < 0.001), respiratory rate (P < 0.001), and SOFA score (P = 0.001) was observed among the responders following 2 hours of therapy. Only one of the responders developed aspiration pneumonitis, as a complication. The daily cost of BiPAP therapy was 8.75 times lower than the average cost of mechanical ventilation.ConclusionThis pilot study reveals that this treatment modality could be a safe, cost-effective and efficacious method of treatment in unconscious patients with acute exacerbation of COPD.

Adjunctive tadalafil therapy for managing pulmonary hypertension in a patient with obesity hypoventilation syndrome

Obesity hypoventilation syndrome (OHS) is often associated with pulmonary hypertension (PH), and noninvasive bi-level positive airway pressure therapy is indicated as first-line treatment. However, its effect in reducing pulmonary arterial pressure is insufficient in many cases, thus adjunctive therapies should be evaluated. In this report, we present a patient with OHS-associated PH who was successfully treated by tadalafil in conjunction with weight reduction and bi-level positive airway pressure therapy.

Sleeping on a Royal Flush

Sleeping on a Royal Flush

Acute ventilatory failure complicating obesity hypoventilation: update on a ‘critical care syndrome’

Obesity can result in serious complications, including obesity hypoventilation syndrome (OHS). OHS patients may present with acute-on-chronic ventilatory failure, necessitating acute care management. The purpose of this review is to discuss the recent literature on acute ventilatory failure in OHS patients. Obese persons can develop acute hypercapnic respiratory failure and sleep hypoventilation due to disorders in lung mechanics, ventilatory drive, and neurohormonal and neuromodulators of breathing. Although there are no clearly defined predictors for OHS patients who are likely to develop acute hypercapnic respiratory failure, most such patients are middle-aged (mid-50s), morbidly obese, and have daytime hypercapnia, hypoxemia, and low serum pH values. Immediate ventilatory support, without sleep study confirmation, is necessary in most such patients. Patients with respiratory acidemia (pH <7.30) or altered mental status may require intensive care unit monitoring. Noninvasive application of bilevel positive airway pressure therapy is the recommended initial ventilatory support under close monitoring. Prompt initiation of noninvasive positive pressure ventilation reduces the need for invasive mechanical ventilation and rapidly improves the levels of blood gases. Obese patients with sleep hypoventilation have an increased risk of acute hypercapnic respiratory failure. Early diagnosis and implementation of noninvasive positive pressure ventilation is recommended for these patients.

Radiofrequency Ablation in the Lung Complicated by Positive Airway Pressure Ventilation

A patient receiving bilevel positive airway pressure therapy underwent radiofrequency ablation of a pulmonary metastasis from a primary malignant fibrous histiocytoma of the scapula. The patient's postablation course was complicated by a bronchopleural fistula, which was exacerbated by the detrimental effects of positive airway pressure on necrotic lung tissue after the ablation. The use of positive airway pressure devices, including bilevel positive airway pressure and continuous positive airway pressure, in patients undergoing radiofrequency ablation of the lung should be considered as an added risk for developing bronchopleural fistula.

Interventions for obstructive sleep apnea in children: A systematic review

Obstructive sleep apnea (OSA) is characterized by habitual snoring, heavy breathing, sleep-related hypoxia and arousals from sleep, and is found in approximately 3% of children. To review the efficacy of medical, behavioral, mechanical and surgical interventions in improving OSA in children. Bibliographic databases, relevant conference proceedings and trial registers were searched. Randomized controlled trials assessing interventions in children with objectively diagnosed OSA (as per polysomnography; apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) > or = 1/h) were considered. The search identified 1690 potentially relevant studies. The five trials that met the inclusion criteria investigated seven different interventions (intranasal steroids, adenotonsillectomy, maxillary distraction, temperature-controlled radiofrequency ablation, oral appliances, continuous and bilevel positive airway pressure therapy). Intranasal steroids had a significant advantage over placebo in decreasing the AHI (one study). Temperature-controlled radiofrequency ablation and adenotonsillectomy were equally effective in reducing the RDI (one study). Continuous and bilevel positive airway pressure therapy was equally effective in reducing the AHI (one study). There was insufficient evidence to support the use of oral appliances. Despite a broad array of treatment options for OSA, there is limited evidence to support their use. More research is needed before general recommendations can be made.

DETERMINANTS OF MINUTE VENTILATION DURING NONINVASIVE VENTILATION OF PATIENTS WITH RESPIRATORY INSUFFICIENCY

PURPOSE: Noninvasive bilevel positive airway pressure (PAP) therapy can improve minute ventilation (VE) in patients with chronic respiratory insufficiency (CRI); however, such therapy is fixed and may not adapt to the varying needs of a patient. We hypothesized that in patients with chronic respiratory insufficiency despite receiving bilevel PAP therapy, VE will decrease with deeper stages of sleep and during supine position when compared to wakefulness and lateral decubitus position, respectively. We also hypothesized that VE during averaged volume assured pressure support (AVAPS) is less susceptible to the influences of sleep-wakefulness state and body position than during bilevel PAP therapy.

From the authors

We are pleased by the great interest in our recently published manuscript 1. In their letter, V. Cottin and co-workers describe the clinical course of a patient with chronic obstructive pulmonary disease (COPD) Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage III and disproportional pulmonary hypertension, who showed considerable benefit from oral bosentan. The authors noted an improvement in 6-min walking test distance of >160 m 2 yrs after initiating bosentan therapy, but also reported a marked increase in carbon dioxide arterial tension levels. Indeed, the case report of V. Cottin and colleagues seems to illustrate the fact that patients with COPD and disproportional pulmonary hypertension could well improve on selective pulmonary vasodilators, despite disadvantageous effects on gas exchange. Nevertheless, with regard to the case report of V. Cottin and colleagues, we believe that the contribution of bilevel positive airway pressure (BiPAP) therapy for possible alveolar hypoventilation (body mass index 41 kg·m2) and residual previous pulmonary embolism might need to be considered in the context of clinical improvement. A further argument supporting the hypothesis that pulmonary hypertension in V. Cottin and colleagues’ case report was not solely related to COPD, …

Practice Parameters for the Use of Continuous and Bilevel Positive Airway Pressure Devices to Treat Adult Patients With Sleep-Related Breathing Disorders

Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBD) including obstructive sleep apnea (OSA). Currently, PAP devices come in three forms: (1) continuous positive airway pressure (CPAP), (2) bilevel positive airway pressure (BPAP), and (3) automatic self-adjusting positive airway pressure (APAP). After a patient is diagnosed with OSA, the current standard of practice involves performing full, attended polysomnography during which positive pressure is adjusted to determine optimal pressure for maintaining airway patency. This titration is used to find a fixed single pressure for subsequent nightly usage. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guideline for using CPAP and BPAP appropriately (an earlier review and practice parameters for APAP was published in 2002). Major conclusions and current recommendations are as follows: 1) A diagnosis of OSA must be established by an acceptable method. 2) CPAP is effective for treating OSA. 3) Full-night, attended studies performed in the laboratory are the preferred approach for titration to determine optimal pressure; however, split-night, diagnostic-titration studies are usually adequate. 4) CPAP usage should be monitored objectively to help assure utilization. 5) Initial CPAP follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed. 6) Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems. 7) Heated humidification and a systematic educational program are recommended to improve CPAP utilization. 8) Some functional outcomes such as subjective sleepiness improve with positive pressure treatment in patients with OSA. 9) CPAP and BPAP therapy are safe; side effects and adverse events are mainly minor and reversible. 10) BPAP may be useful in treating some forms of restrictive lung disease or hypoventilation syndromes associated with hypercapnia.